Steubenville Conference Application for Males July 23-25

All fields are required to submit application.

Retreatant Information:

Student's Full Name*

Gender*

Age on July 23, 2021*

Grade level in Fall 2021*

T-Shirt Size (Adult sizes only)*

Student and Parent Contact Information:

Student Cell Phone Number*

Student Email Address*

Enter Email Confirm Email

Parent/Guardian Email Address*

Parent/Guardian Cell Phone Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Name*

Emergency Contact Phone Number*

Emergency Contact Relationship

Please list any allergies, medications, or any other information that we need to know.

Do you have a coupon code?*

No
Yes

Coupon Code*

Would you prefer to charge as a one-time payment of $300 or 2 monthly payments of $150?*

Includes conference admission, transportation, lodging, all meals and 2 group t-shirts.

One-Time Payment*

Price: $300.00

Two Monthly Payments*

Price: $150.00

*Note: Initial charge of $150 will be collected upon submission and the remainder of $150 will be collected on the same card after 30 days.

*

By checking the box above, I, the authorized card-holder of the credit card entered below, authorize ECRC to automatically deduct $150 now and $150 one month from now. I will not hold ECRC liable for any unauthorized billing charges. If the payment fails the second time, I am still responsible for providing the remainder of the amount due, otherwise this registration may not be valid for attending the retreat.

Total

$0.00

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Terms & Conditions*

There is certain behavior and certain expectations that are encouraged on this journey. I understand that this journey is to focus on my personal relationship with God. I agree that if I am found in possession of or participating in any way with drugs or alcohol, parent/guardian will be called and I will not be allowed to participate in any activities socially, only spiritually. I further understand that this is a coordinated by our Catholic Chaldean Church and I am expected to participate in all planned meetings and activities and abide by all rules. By checking the box above, I am agreeing with all terms mentioned and all my information that I completed above is true.

Steubenville Conference Application for Males July 23-25

Steubenville Conference - Male July 23-25, 2021

Retreatant Information:

Student and Parent Contact Information: